Healthcare Provider Details

I. General information

NPI: 1497684047
Provider Name (Legal Business Name): SAMANTHA LYNN CHILDRESS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 SAND PEBBLE DR STE A
JACKSON TN
38305-7591
US

IV. Provider business mailing address

805 LOCKE RD
POCAHONTAS TN
38061-4401
US

V. Phone/Fax

Practice location:
  • Phone: 901-443-9146
  • Fax:
Mailing address:
  • Phone: 901-443-9146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: